Case Report

Tension Caused by Obstipation

Daniel Miller, MD, FACEP University of Iowa Hospitals and Clinics, Department of Emergency Medicine, Iowa City, Iowa

Section Editor: Rick A. McPheeters, DO Submission history: Submitted December 23, 2014; Revision received May 13, 2015; Accepted June 3, 2015 Electronically published October 20, 2015 Full text available through open access at http://escholarship.org/uc/uciem_westjem DOI: 10.5811/westjem.2015.6.25283

Emergency physicians are often required to evaluate and treat undifferentiated patients suffering acute hemodynamic compromise (AHC). It is helpful to apply a structured approach based on a differential diagnosis including all causes of AHC that can be identified and treated during a primary assessment. Tension pneumoperitoneum (TP) is an uncommon condition with the potential to be rapidly fatal. It is amenable to prompt diagnosis and stabilization in the emergency department. We present a case of a 16-year-old boy with TP to demonstrate how TP should be incorporated into a differential diagnosis when evaluating an undifferentiated patient with AHC. [West J Emerg Med. 2015;16(5):777-780.]

CASE rectus musculature, and we advanced each needle until a rush A 16-year-old Hispanic male presented to our emergency of air was heard. As air was evacuated the patient’s abdominal department (ED) with difficulty breathing that his mother distension visibly resolved. We soon noted decreased airway first noted on the previous night. He had a history of resistance and improved aeration. Within minutes the patient’s muscular dystrophy (MD), frequent seizures and severe blood pressure improved to 93/47mmHg, and his pulse developmental delay causing him to be non-verbal at oximetry waveform became detectable at 93%. A repeat chest baseline. He also had a long-standing history of . radiograph showed markedly improved pneumoperitoneum His mother had not noted any new symptoms until the and diaphragmatic excursion with persistently dilated loops of previous night when he appeared to develop difficulty bowel (Figure 3). breathing. Upon arrival to the ED he was found to be in The patient was then taken to the operating room where respiratory distress. His vital signs were significant for he was found to have purulent , and a 1.5cm the following: heart rate 144 beats/minute; blood pressure cecal perforation was identified and repaired. A large rectal of 43/22mmHg; temperature of 35.2ºC; and respiratory scybalum was also noted, and as there was no other bowel rate of 44 breaths/minute. Pulse oximetry waveform was pathology identified during , the cause of our initially undetectable. On initial exam we noted markedly patient’s bowel perforation was determined to be obstipation. but symmetrically diminished lung aeration, a tensely We suspect that his preexisting communication difficulties distended and mottled skin with cyanosis. When caused a delay in presentation, allowing his constipation to we attempted supplemental ventilation with bag valve mask progress to bowel perforation. we noted high airway pressures. Concurrent with obtaining intravenous access and placing the patient on continuous DISCUSSION monitoring, we obtained portable supine chest (Figure 1) and Pneumoperitoneum is a radiographic term defined as left lateral decubitus abdominal (Figure 2) radiographs. free air within the peritoneal cavity. This finding usually After noting massive pneumoperitoneum and elevation suggests a perforated viscous, but up to 15% of cases of the diaphragm we suspected tension pneumoperitoneum occur in the absence of perforation.1 Pneumoperitoneum (TP) as the cause of shock. We positioned the patient in the can occur post-procedurally or from passage of air from right lateral decubitus position and placed three 14-gauge thoracic, abdominal, gynecologic or idiopathic sources needles through the left abdominal wall, just lateral to the (Table). Post-procedural pneumoperitoneum can follow

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Figure 1. Initial chest x-ray demonstrating elevated diaphragm Figure 3. Chest x-ray performed after needle decompression (black arrows). of abdomen demonstrating improved diaphragmatic excursion (black arrows).

diaphragmatic defects or perivascular connective tissue, allowing the to communicate with the . Pneumoperitoneum from abdominal sources occur through perforation of a hollow viscous, gas-forming bacterial (abscess or peritonitis) or rupture of gas- filled cysts within the alimentary tract wall ( cystoides). Gynecologic sources of pneumoperitoneum are a result of the anatomic communication between the fallopian tubes and the peritoneal cavity and can occur under any circumstances that cause the pressure of air within the gynecologic organs to exceed the intraabdominal pressure (IAP) (mean IAP is between 16 and 20mmHg with a maximum of 25.5mmHg in non-pathologic states).4 The rate of pneumoperitoneum caused by processes that do not require surgical intervention has been estimated at 10%, so it is helpful to divide pneumoperitoneum into surgical and non-surgical categories.5 A method has been proposed to identify cases of pneumoperitoneum that do not require Initial abdominal film, in left lateral decubitus position Figure 2. surgical intervention. If all of the following criteria are met demonstrating large amount of free air (black arrows), dilated loops of bowel (double white arrows) and inferior and medial it may be reasonable to consider non-surgical management: displacement of the liver (“saddle bag sign” [triple clear arrows]). pneumoperitoneum is identified incidentally, there is a benign alternative explanation for the presence of air, there is no free fluid in the abdomen, and there are no percutaneous tube placement, laparotomy, signs of peritonitis or sepsis.6 While this method has not and . After laparoscopy air is expected to be been prospectively validated, it is reasonable to consider visible on imaging for one week but may last up to four managing with advanced imaging and serial examinations weeks.2 Approximately 0.1% of endoscopic procedures in these potentially non-surgical cases. will result in pneumoperitoneum.3 The majority of these TP is an extreme form of pneumoperitoneum that cases are the result of microperforation and do not result in occurs when intraabdominal free air reaches pressures peritonitis. In thoracic sources high intrathoracic pressure high enough to impede venous return to the heart and to leads to introduction of air into the peritoneum via either inhibit diaphragmatic excursion. Diminished venous return

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Table. Causes of pneumoperitoneum. perforation.7 TP has since been reported as a complication Category Cause of bowel perforation secondary to endoscopy, peptic ulcer 8-12 Abdominal Anastomotic leak disease and . It is theorized that TP results from viscous perforation when overlying omental Collagen vascular diseases fat acts as a one-way valve, allowing gas to reach high (jejunal or sigmoid) pressures in the peritoneal cavity. It appears that - Perforation of hollow viscus induced TP without any viscous perforation is particularly Pneumatosis cystoides intestinalis rare, but this has also been reported.13 Of particular interest Rupture of intra-abdominal abscess to emergency physicians are cases of TP following positive Gynecologic Coitus pressure ventilation during cardiopulmonary resuscitation with associated gastric rupture.14,15 Because the air is Knee-chest exercise extraluminal, a gastric tube will not improve ventilation Pelvic inflammatory diseases in these cases. Upon our review of the literature, we were Post-partum exercise unable to identify any previously reported cases of TP Vaginal insufflation caused by constipation. We suspect that our patient’s history Vaginal douching of MD, combined with his non-mobile and non-verbal Thoracic Adenotonsillectomy status resulted in this novel presentation of TP. MD is Asthma known to be associated with increased colonic transit times, resulting not only from direct damage to smooth muscle, Barotrauma/thoracic trauma but also due to immobility and weak abdominal musculature Bleb rupture (spontaneous) contributing to constipation.16,17 Additionally, our patient Bronchopulmonary was non-verbal. His inability to communicate his symptoms Bronchoscopy allowed his condition to progress unnoticed until it resulted Cardiopulmonary resuscitation (can in spontaneous perforation of his colon, a condition more occur from blunt trauma, positive commonly described in elderly patients with constipation.18 pressure ventilation or both) His non-verbal status further allowed this catastrophe to go Pneumothorax/ unnoticed until it led to TP and its associated respiratory Positive end-expiratory pressure distress, the symptom that prompted his mother to bring him ventilation to the ED for evaluation. Pulmonary tuberculosis The diagnosis of TP should be suspected in patients who Severe coughing present with respiratory distress associated with abdominal distension. Physical exam findings reveal high airway Post-procedural Laparoscopy/laparotomy pressures, a tensely distended abdomen and poor systemic Endoscopy perfusion in TP. This diagnosis can be supported by chest Gynecologic examination procedures and abdominal radiographs showing low lung volumes and a Postpolypectomy syndrome large amount of intraperitoneal free air. Sometimes the liver Percutaneous enteric tube can also be observed to be inferiorly and medially displaced placement/displacement (the “saddle bag” sign). Initial treatment of TP consists of percutaneous needle decompression. The vast majority of Other Gas forming bacterial infection reported cases of TP are associated with a perforated viscous. These patients should be emergently transferred to the Idiopathic operating room for diagnostic and therapeutic laparotomy unless there is highly compelling evidence to suggest that no such perforation has occurred. leads to decreased diastolic filling thereby decreasing cardiac output. This manifests as hypotension and CONCLUSION decreased systemic perfusion. Inhibition of diaphragmatic TP should be included in the differential diagnosis when excursion decreases tidal volume. If the patient is unable assessing undifferentiated patients presenting to the ED with to compensate with an increased respiratory rate this acute hemodynamic compromise. These patients present will result in decreased minute ventilation and manifest with hypotension, respiratory distress, a tensely distended as hypercarbic respiratory distress. If not diagnosed and abdomen and high inspiratory pressures. The diagnosis treated promptly, TP will rapidly lead to death. of TP can be supported by portable radiographs, and it TP was first described in the medical literature by can be confirmed with diagnostic and therapeutic needle Oberst in 1917 when a grenade explosion resulted in gastric decompression of the abdomen.

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Address for Correspondence: Daniel Miller, MD, FACEP, accompanied by tension pneumoperitoneum. Yonsei Med J. University of Iowa Hospitals and Clinics, 200 Hawkins Drive, 1008 2000;41(4):533-535. RCP, Iowa City, IA 52242. Email: [email protected]. 8. Kealey WD, McCallion WA, Boston VE. Tension pneumoperitoneum: a potentially life-threatening complication of percutaneous endoscopic Conflicts of Interest By the WestJEM article submission : gastrojejunostomy. J Pediatr Gastroenterol Nutr. 1996;22(3):334-335. agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that 9. Ortega-Carnicer J, Ruiz-Lorenzo F, Ceres F. Tension could be perceived as potential sources of bias. The authors pneumoperitoneum due to gastric perforation. Resuscitation. disclosed none. 2002;54(2):215-216. 10. Hector A. Pneumoperitoneum under tension in peritonitis due Copyright: © 2015 Miller. This is an open access article distributed to digestive tract perforation (apropos of 15 cases). Actual in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) License. See: http://creativecommons.org/licenses/ Hepatogastroenterol. 1968;4(4):153-163. by/4.0/ 11. Devine JF and McCarter TG. Tension Pneumoperitoneum, Images In Clinical Medicine. N Engl J Med. 2001;344:1985. 12. Canivet JL, Yans T, Piret S, et al. Barotrauma-induced tension REFERENCES pneumoperitoneum. Acta Anaesth Belg. 2003;54,233-236. 1. Roh JJ, Thompson JS, Harned RK, et al. Value of pneumoperitoneum 13. Mills SA, Paulson D, Scott SM, et al. Tension pneumoperitoneum and in the diagnosis of visceral perforation. Am J Surg. 1983;146(6):830-3. gastric rupture following cardiopulmonary resuscitation. Ann Emerg 2. Gayer G, Jonas T, Apter S, et al. Postoperative pneumoperitoneum Med. 1983;12(2):94-5. as detected by CT: prevalence, duration, and relevant factors 14. Cameron PA, Rosengarten PL, Johnson WR, et al. Tension affecting its possible significance. Abdom Imaging. 2000;25:301-5. pneumoperitoneum after cardiopulmonary resuscitation. Med J Aust. 3. Mularski RA, Ciccolo ML, Rappaport WD. Nonsurgical causes of 1991;155(1):44-7. pneumoperitoneum. West J Med. 1999;170:41-6. 15. Perkin GD and Murray-Lyon I. Neurology and the gastrointestinal 4. Cobb WS, Burns JM, Kercher KW, et al. Normal Intraabdominal system. J Neurol Neurosurg Psychiatry. 1998;65:291–300. Pressure in Healthy Adults. J Surg Res. 2005;129(2):231–235. 16. Gottrand F, Guillonneau I, Carpentier A. Segmental colonic 5. Cecka F, Sotona O, Subrt Z. How to distinguish between surgical and transit time in Duchenne muscular dystrophy. Arch Dis Child. non-surgical pneumoperitoneum? Signa Vitae. 2014;9:1. 1991;66(10):1262. 6. Oberst, A. Das Spannungspneumoperitonaion. Zentralbl f Chir. 17. Yang B and Huai-Kun N. Diagnosis and treatment of spontaneous 1917;44:354-355. colonic perforation: Analysis of 10 cases. World J Gastroenterol. 7. Kim SJ, Ahn SI, Hong KC, et al. Pneumatic colonic rupture 2008;14(28):4569-4572.

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